Courteous to the core

Unwritten rules guide referral etiquette

The etiquette of referrals requires keeping patients' needs paramount and respecting core aesthetic physicians who send you consults, said panelists at The Cosmetic Bootcamp, recently.

Dr. RohrichRod J. Rohrich, M.D., says that as a core aesthetic specialist, "We see a lot of cross-fertilization in aesthetic medicine. And sometimes we don't. It depends where you live – we often see cases where patients aren't referred who should be." He is professor and founding chairman of the Department of Plastic Surgery at the University of Texas Southwestern Medical Center in Dallas.

Some patients considering surgical procedures might need medical skin treatments first, he says. Conversely, he tells dermatologists, "If a patient has jowling and loose neck skin, and they've been your filler patient forever, this is the time to be honest and say, 'We must do true surgical lifting, versus filling.' We all want what's best for patients."

He and fellow panelists also offer the following guidelines:

Respect the referrer

Dr. LupoMary P. Lupo, M.D., collaborates with several colleagues in her region. She often refers patients to plastic surgeons when they need surgery and considers herself to be an expert on lasers, peels and injectables. Frequently, she will see patients from other physicians who need her level of skill.

She is always careful to return the patient to the referring physician. However, says Dr. Lupo, if a dermatologist gets a referral from a non-core specialist, such as an OB/GYN who performs injectable treatments but is concerned about a patient's mole, "It's OK to treat these patients. It's all about what's best for the patient," and patients are best served by having dermatologists treat their skin issues. She is a New Orleans-based dermatologist and clinical professor of dermatology at Tulane University School of Medicine.

In such cases, Dr. Rohrich advises taking the high road. "Don't say anything about the referring physician. I say, 'I'm an expert in doing these things, and I will take care of you.'" If patients choose to return to a non-core specialist for aesthetic treatments, "That's their prerogative."

Exit gracefully

Often, says Dr. Lupo, someone may want to stay with your practice for future aesthetic treatments that their referring physician also offers, saying that you know their face best. "I tell the patient, 'I do not feel comfortable taking away what your doctor has been doing for you. But if you want to talk it over with your doctor and have them call me to do your filler, I'll be happy to do that."

Dr. BeerKenneth Beer, M.D., says that if a referral patient wants to stick with his practice, "I say, 'I'd love to help you, but you were sent here for a very specific issue. We've resolved that issue. It's time to go home.'" He is an associate clinical professor of dermatology at the University of Miami Miller School of Medicine, a consulting associate with Duke University, and a clinical associate in dermatology, University of Pennsylvania Perelman School of Medicine.

Additionally, Dr. Rohrich suggests notifying the referring physician of the patient's request – and that you directed the patient back home.

Know your limits

Dr. MontesJosé Raúl Montes, M.D., says, "I try to confine myself to things I believe I do better than anyone," namely, oculoplastic surgery and temporary injectable treatments. If a patient wants a permanent filler, "I say to myself, 'I know where this patient is going. But they're not staying here.'" He is a San Juan, Puerto Rico-based oculoplastic surgeon and associate professor, Ophthalmology Department, University of Puerto Rico School of Medicine.

Timothy Greco, M.D., says, "If I get a patient who is severely retrognathic and their dentition is way off, and they don't just want a chin implant, I send that patient to an oromaxillofacial surgeon." He is an adjunct assistant professor in the University of Pennsylvania School of Medicine Department of Otolaryngology - Head and Neck Surgery.

If a plastic surgeon sends a patient with acne, rosacea or melasma to their own aesthetician instead of a dermatologist, adds Dr. Lupo, "You're doing that patient a tremendous injustice." She once saw that an aesthetician had posted a picture of an olive-skinned patient with melasma and rosacea online and asked whether IPL or Fraxel (Solta Medical) would be best for the patient. "My answer was none of the above. The most dangerous medical provider is the one who doesn't know what they don't know."

Trust your gut

Should a referral patient have unrealistic expectations, Dr. Rohrich advises, "Tell the patient, 'I'm not good enough to give you the result you want.' It's very important to say that verbatim" and not let the patient manipulate you into performing an ill-advised or unnecessary procedure that will make them look unnatural or different – e.g., the Hollywood "windswept" look or overdone lips and cheeks, he says.

Dr. GrecoFinally, Dr. Greco says, if a patient really doesn't need your services, "There's nothing wrong with telling a patient they don't need anything. Those will be your most grateful patients because they respect the fact that you were honest."

Dr. Rohrich adds, "Every patient you inject is a walking advertisement. If you overfill them, you may get a better check that day," but long-term, you'll pay. The patient will not be happy or look natural and youthful, which he says is the ideal result – "a patient who looks great, and young, without looking like she has had plastic surgery or fillers."

Disclosures: Dr. Lupo is a partner in The Cosmetic Bootcamp. Dr. Beer is a partner in The Cosmetic Bootcamp and Theraplex and a consultant, speaker and clinical trial investigator for Allergan and Galderma. Dr. Montes is a speaker, trainer and consultant for Allergan, Galderma, Merz Aesthetics and Valeant. Dr. Rohrich is a volunteer member of the Allergan Alliance for the Future of Aesthetics. He receives instrument royalties from Eriem Surgical Inc. and book royalties from Taylor & Francis Group. Dr. Greco reports no relevant financial interests.

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